Las reformas a la protección social en salud en México: ¿rupturas o continuidades?Mónica Uribe Gómez * Raquel Abrantes Pêgo ** Resumen Desde la década de los ochenta comenzó un proceso de reformas al sistema de salud mexicano con el fin de promover cambios estructurales en el sector mediante una mayor presencia del sector privado. Se argumenta que la reforma fue propuesta por un grupo de actores tecno-burocráticos que han concentrado recursos de poder cruciales para modificar las reglas institucionales y que tales cambios se han llevado a cabo sin consultar ampliamente a los diversos actores interesados: gobiernos de los estados de la república, proveedores de los servicios públicos y usuarios.
AbstractThis paper examines the reform process within the Mexican health system undertaken since the eighties that led to an increasing privatization of health services. It argues that such process have been led by a small group of techno-bureaucratic actors that have changed institutional rules according to their interests without considering the interests of local governments, public services providers and public health services users.Palabras clave: reforma de la atención de salud, protección social en salud, Seguro Popular, proceso político, México.
Although it is well known that a successful implementation depends on the front-liners’ knowledge and participation, as well as on the organizational capacity of the institutions involved, we still know little about how front-line health workers have been involved in the implementation of the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ). This paper develops a contingent mixed-method approach to explore the perceptions of front-line health workers - managers, nurses, community health workers, and doctors - regarding the PMAQ (2nd round), and their evaluations concerning health unit organizational capacity. The research is guided by three relevant inter-related concepts from implementation theory: policy knowledge, participation, and organizational capacity. One hundred and twenty-seven health workers from 12 primary health care units in Goiânia, Goiás State, Brazil, answered semi-structured questionnaires, seeking to collect data on reasons for adherence, forms of participation, perceived impact (open-ended questions), and evaluation of organizational capacity (score between 0-10). Content analyses of qualitative data enabled us to categorize the variables “level of perceived impact of PMAQ” and “reasons for adhering to PMAQ”. The calculation and aggregation of the means for the scores given for organizational capacity enabled us to classify distinct levels of organizational capacity. We finally integrated both variables (Perceived-Impact and Organizational-Capacity) through cross-tabulation and the narrative. Results show that nurses are the main type of professional participating. The low organizational capacity and little policy knowledge affected workers participation in and their perceptions of the PMAQ.
This study focuses on the role of public health experts in the contemporary health sector reform process. The authors discuss the issue based on the case of Brazil and Mexico, where a group of public health specialists have oriented their participation to influence the conflict concerning health policy reform in the respective countries. One approach has been to develop a new cognitive framework for technical health sector reform projects viewed as policy proposals with technical content. The purpose is to demonstrate how these specialists have managed to influence the national debate over health sector reform when the technical and scientific discussion leaves the academic sphere and reaches the social and political realm. The authors contend that this occurs because such technical and scientific knowledge has been postulated (independently of its intrinsic value) as a political and ideological alternative platform for sustaining a health sector reform proposal which, once transformed into a policy project, has served to aggregate certain political and social forces.
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